Living with low vision

Monica Perlmutter, OTD, OTR/L, SCLV, FAOTA, helps adults and older adults with age-related vision loss maximize their participation

by Michele Berhorst • December 22, 2023

Perlmutter (left) demonstrates the use of bump dots on the microwave button to Lettie Cunetto (right).

Despite having several strokes and resulting challenges, Lettie Cunetto remains positive about life and her future with her husband, Frank. Following the first two strokes, Lettie was able to resume most of her daily activities because only her left eye was impaired. The third stroke, however, resulted in vision loss in her right eye and also impacted her ability to interpret what she was seeing and her memory. “It really knocked me for a loop. It’s been challenging every day, but not as challenging as learning new ways to do the things I used to, like reading, watching television, using my iPad, cooking and self-care,” Lettie shares “I wake up every morning, and my vision is different. Sometimes it’s good and other times, not so good.”

Before Lettie was discharged from the hospital, her husband, Frank, began modifying their home to make it safer for her return. He removed the throw rugs, gated off doors and stairs, and even modified their walk-in closet. “Some of my ideas like a bed alarm or putting a bar across the upstairs window to prevent falls didn’t fly,” Frank admits. “She wants to do everything she can. An added challenge is short-term memory loss from the stroke. I can show her how to do something, but she doesn't always remember.”

The Cunettos made progress on several of Lettie’s goals, but she wanted to do more. Her doctor, Leanne Stunkel, MD, who specializes in neuro-ophthalmology, referred the couple to Monica Perlmutter, OTD, OTR/L, SCLV, FAOTA, the lead occupational therapist for the aging and low vision services in Washington University Occupational Therapy’s (WUOT’s) Community Practice.

Area of practice

Perlmutter, an associate professor of occupational therapy and ophthalmology and visual sciences, has specialized in low vision rehabilitation for nearly half of her 43-year career. Perlmutter earned her bachelor's degree in occupational therapy from the University of Missouri-Columbia in 1981. She then worked in acute neurology, inpatient and outpatient rehabilitation, general medicine, and orthopedics at the Irene Walter Johnson (IWJ) Institute of Rehabilitation at Washington University for 13 years; during this time, she also served as coordinator of clinical education and staff development for IWJ. She earned her master’s degree in higher education from Washington University in 1989 and joined the Program’s faculty as an instructor in occupational therapy in 1992.

Transitioning to low vision rehabilitation required a bit of a leap into the unknown. “I was at a point in my career where I was ready for a new challenge. I had a five-year gap when I was primarily teaching and missed seeing patients. In the early 2000s, Community Practice was starting up at the Program. Community Practice was very innovative at this time due to the community-based focus and the diversity of the practice areas and specialty services that were offered,” Perlmutter recalls. “I told then director Carolyn Baum, PhD, OTR, FAOTA, that I was interested in getting involved in the Community Practice efforts. She encouraged me to start the Low Vision Practice when the Washington University Physicians optometrist Carrie Gaines, OD, reached out and expressed interest in partnering with an occupational therapist. I knew nothing about this area of practice but was intrigued.”

Perlmutter was given the time to market the new service and build a referral network. “I created a presentation for providers with a focus on retina, cornea and glaucoma specialists,” Perlmutter says. “I also formed relationships with community partners such as the St. Louis Society for the Blind and Visually Impaired (SLSBVI). I knew I needed to work with a team of providers and the support of these resources and organizations to best serve my clients. Since this was a new area of practice, I also had to educate referral sources, clients and families about the low vision services occupational therapy provided.”

To further her education and expertise, Perlmutter earned her graduate certificate in low vision rehabilitation in 2009 from the University of Alabama at Birmingham, the preeminent low vision rehabilitation program for occupational therapists in the world. She also earned her clinical doctorate in occupational therapy from Washington University School of Medicine in 2012.

For the next 10 years following completion of her OTD, Perlmutter continued her roles as educator, clinician and researcher. She developed two key components of the entry-level curriculum with the case-based learning (CBL) team to improve core clinical competencies: the CBL course series and the standardized patient experiences course. She took on a research role as co-investigator on a National Institutes of Health grant with principal investigator Anjali Bhorade, MD, Peggy Barco, OTD, OTR/L, SCDCM, CDRS, FAOTA, and other team members to study driving errors and compensatory strategies in older adults with glaucoma from 2016-21.

Throughout the years, Perlmutter has shared her passion for working with adults and older adults with vision loss with the students she has mentored in her Low Vision Laboratory. Within the lab, she and her students developed a self-management (SM) program for adults with vision loss to support participation. “We partnered with SLSBVI and other agencies to deliver the SM program. The SLSBVI was generous with helping us recruit participants, allowed us to use their space free of charge, and provided other means of support,” Perlmutter says. “My lab students were very involved in program development and delivery and in collecting program evaluation data. In another project, students helped develop and trial SM toolkits for use in direct care with clients with chronic conditions.”

One of her community partners was the Pepose Vision Institute, whose ophthalmologists implanted an FDA-approved miniature telescope into the eye for a select group of individuals with macular degeneration. “The exciting thing about it was that the FDA protocol included the role of occupational therapy. Post-implant, an occupational therapist worked with patients for 8–10 weeks on how to use their telescope to spot view, read, and guide hand-directed activities, as well as for mobility. Patients often used the miniature telescope in combination with other magnification devices. It took a lot of effort on their part to learn and practice these skills,” Perlmutter shares. “I worked with Jennifer Lauer, OTD, who is with SLSBVI now, to build the rehab program. Unfortunately, the program is no longer being offered in our area currently.”

Today, Perlmutter’s referral base includes renowned Washington University physicians in neuro-ophthalmology, ophthalmology and neurology. “I see people with stroke, brain injury and tumors, vision changes due to Parkinson's disease, posterior cortical atrophy, macular degeneration, diabetic retinopathy, glaucoma and other eye conditions.”

Perlmutter was nationally recognized for her work in the area of low vision when she was inducted into the American Occupational Therapy Association’s Roster of Fellows in 2016. Locally, she was honored for her commitment and community involvement with the SLSBVI Community Light Award in 2022.

Meeting goals

During their first occupational therapy visit, the Cunettos made a list of activities Lettie wanted to work on in collaboration with Perlmutter. “I think the first thing I said was cooking, because the doctors said to stay away from appliances, sharp objects and hot surfaces. Frank was doing all the cooking, but I wanted to do simple, safe cooking myself,” Lettie recalls. “So Monica put bump dots on the microwave buttons so I could feel which one was which.”

“Her depth perception has decreased, so we worked on modifying self-care tasks or adding tactile cues. For example, Lettie was having issues putting the toothpaste on the toothbrush. We solved it by having her squirt toothpaste directly into her mouth,” Perlmutter shares. “Another modification included putting a rubber band around the conditioner bottle so she could distinguish it from the shampoo bottle.”

Perlmutter also made home visits to modify the environment to make it safer for Lettie to move about freely. “Our first priority was fall prevention, so I put blue tape on the first and last stair of the landing transition to increase visibility. I recommended Lettie take a ‘graceful pause’ before descending the stairs and also take her time as she shifted from one handrail to the next.”

Perlmutter referred the Cunettos to the services SLSBVI provides for the visually impaired. “The optometrist on site recommended glasses with FL-41 lenses, a specialty tinted lens designed for people with light sensitivity,” Frank says. “They help her with eye fatigue both indoors and outdoors.” The SLSBVI also provided technology assistance so Lettie could use her iPad again. “I did so many things on my iPad: work, shopping, email. I’m slowly trying to get better at using it because I miss it, and it's so much fun,” Lettie shares. “I’ll keep working at it.”

The Cunettos worked with Perlmutter over the course of two months. However, they may reconnect with her in the future for more modifications when they move into a new home. “Working with Monica was wonderful. She’s very professional but also so delightful. She helped me regain my independence and confidence,” Lettie says.

Passing the baton

Perlmutter is set to retire in June 2024 after 32 years in the Program in Occupational Therapy. She will be leaving the Low Vision Practice in the capable hands of her daughter, Anna Perlmutter, MSOT, OTR/L, an occupational therapist in WUOT’s Community Practice.

“Anna is a tremendous advocate for her clients. That comes through in every conversation I have with her. She is working on her low vision rehabilitation graduate certificate at the University of Alabama Birmingham. I have every confidence that she will be a tremendous resource for this client population and the program,” Perlmutter shares.

When asked if she has any advice to share with Anna, Perlmutter says, “I want her to say yes to opportunities that will help her grow the practice and continue to build community partnerships. She’s off to a wonderful start.”

For the profession at large, Perlmutter’s hope is for this area of practice to continue to grow. “We have an aging population, and future needs are going to be even greater than they are now. I would love to see general practitioners gain some of the base skills and knowledge to address non-specialized needs of individuals with vision loss and know when to refer to a specialist,” Perlmutter says. “And of course, I’d love to see more low vision specialists in the future as well as continued efforts to build evidence to support this important area of practice.”

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